Atrial Fibrillation t

1874 Alfred Vulpian- ‘Fremissement fibrillaire’ 1876 Carl Nothnagel- ‘Delerium Cordis’

1906- Einthoven- 1 st EKG of afib Rothberger,Winterberg& Lewis- correlation between EKG and pulse

Atrial Fibrillation-Atrial Fibrillation- –Absent ‘P’ waves –Irregular atrial activity- ‘F’ waves Variable- amplitude, duration and morphologyVariable- amplitude, duration and morphology –Resultant irregular ventricular response –Impostures- atrial flutter and MAT

Classification First detected- single documented episode Recurrent- 2 or more episodes Paroxysmal- Spontaneous conversion (usually <7 days) Persistent- episodes are sustained (often >7 days) Permanent/Chronic- persistent (typically > 1year)

Etiologies Valvular Heart Disease- esp. Mitral Non valvular and Secondary causes –Cardiomyopathies (IDCM/NIDCM) –Hypertension –Post-CABG/Post operative state –Toxin- Thyrotoxicosis, ETOH –Pulmonary embolus/COPD –Hypoxia/Acidemia –Sinus Node dysfunction –Congenital Heart disease- WPW, ASD Lone Atrial Fibrillation –<12% without identifiable cause –Age <60

Conditions Allied with AF

Copyright restrictions may apply. Go, A. S. et al. JAMA 2001;285: Prevalence of Diagnosed Atrial Fibrillation Stratified by Age and Sex In General- <1% of Population < 60 yrs >6-8% of Population >80 yrs

Copyright restrictions may apply. Go, A. S. et al. JAMA 2001;285: Projected Number of Adults With Atrial Fibrillation in the United States Between 1995 and 2050

Concerns Thromboembolism Mortality Cardiomyopathy and CHF As well as –Known Knowns –Known Unknowns –Unknown Unknowns

Copyright ©2001 American Heart Association Fuster, V. et al. Circulation 2001;104: Relative risk of stroke and mortality in patients with AF compared with patients without AF Risk of CV ~5% per year with risk factors Annual CVA risk 23.5% for those aged 80 to 89 years

Copyright ©2005 American Heart Association Verma, A. et al. Circulation 2005;112: Kaplan-Meier curves describing survival in post- coronary bypass surgery patients at the Cleveland Clinic from 1972 to 2000

AF and CVA Risk Factors CHADS2 –Hypertension- even a history thereof =1 –Diabetes =1 –Congestive heart failure =1 –Age >75 years –Prior TIA/CVA = 2 Others –Prior MI –Echo data- LV dysfunction (EF<35-40%), Left atrial enlargement –Some argue age >60 or 65 BF Gage et al. JAMA : Krahn AD et al. Am J Med. 1995;98: Atrial Fibrillations Investigators. Arch Intern Med. 1998;158:

Risk for CVA: CHADS2 Score CVA risk/Yr 01.9% 12.8% 24.0% 35.9% 48.5% 512.5% 618.2% BF Gage et al. JAMA :

AF and Cardiomyopathy Rawles (Br Heart J 1990;63:157-61) -↓C.O. with HR>90 Tachycardia-induced Cardiomyopathy- may occur with heart rates ≥ BPM over days –Reversible with proper rate control –Symptoms vary between patients Rate Control –AFFIRM Resting HR ≤ 80 BPM 24 Hour Holter- Avg HR ≤ 100 BPM and no HR > 110% MTHR HR ≤ 110 BPM during 6 minute walk test Shinbane et al. J Am Coll Cardiol 1997;29: NHLBI AFFIRM investigators Am J. Cardiol 1997;79:

AF in CHF: Prognostic Implications V-HeFT no effect of AF on mortality …but SOLVD found RR 1.34, p=0.002 (Cox) Framingham HR for death 1.6 in males; 2.7 females (Cox) V HeFT found no effect of AF on survival

Prevalence of AF and CHF 80% in “dropsy” –Mackenzie J. The Oxford medicine, 1920: Clinical Trial data 15-30% AF, higher with worse NYHA –Ehrlich, Nattel, and Hohnloser, JCE :

AF and CHF- in sum AF and CHF appear to co-promote While treatment of LV dysfunction prevents AF, converse not clear (except in poorly rate-controlled subjects) Clinical trial data highly desirable –AF-CHF –Randomized study of non-pharmacologic treatment in subjects with LV dysfunction Circulation. 2008;118:S_827

Prevention of CHF by treatment of AF Ablate and pace –Uncontrolled studies show improvements in LV function –Controlled study- improved dyspnea and exercise tolerance but not LV function Circulation 1998;98: Mayo experience- does not alter prognosis –NEJM 344: Bi-V might be better –Eur Heart Journal :

Can We fix it? Management Strategies –Rate Control Pharmacologic Non-Pharmacologic –Rhythm Control Anti-arrhythmics Surgical ‘correction’ Percutaneous ‘correction’ –Prevention

Rate vs. Rhythm Fuster et al. JACC.2006;48(4):e No significant difference in mortality -Anticogulation is essential regardless of strategy

Fuster, V. et al. Circulation 2001;104: Pharmacological management of patients with newly discovered AF Assess for underlying disease: Echocardiogram Ischemic Heart diesase Endocrine disease OSA CVA Risk Stratify

Rate Control Strategy AV nodal blocking Agents –Beta-receptor antagonists –Non-dihydropyridine Calcium channel blockers –Digoxin-indirect via vagal effects Ablate and Pace

Rate control strategery Farshi et al. JACC 1999; 33(2): Dig-βb

Mayo Ablate and pace experience NEJM 344:

Rhythm Control Simplified Fuster et al. JACC.2006;48:

Fuster, V. et al. Circulation 2001;104: Arrhythmia-free survival after electrical cardioversion in patients with persistent atrial fibrillation DCC- >87% successful in most patients Only 25-35% of patients will be in sinus rhythm at one year Kastor, J.A. Arrhythmias, Second Edition W.B. Saunders Co : pp79-81

Anti-arrhythmics Fuster et al. JACC.2006;48(4):e

Dronedarone -Contraindicated in Class IV CHF

Roy, D. et al. N Engl J Med 2000;342: Percentage of Patients Remaining Free of Recurrence of Atrial Fibrillation 18% of the patients receiving amiodarone and 11% of patients receiving sotalol or propafenone had to discontinue therapy because of adverse effects

RACE II

Surgical Modification Cox-Maze Several Modifications Variable results –? Data Still considered the ‘Gold Standard’

Dr. Cox?

Evolution of percutaneous AF ablation 1994 John Swartz first reports endocardial maze procedure 1998 Haissaguerre isolates pulmonary vein “culprit” more PVs, more foci 2003 Pappone anatomic approach 2004 Morady Need to isolate 4/4 veins 2004 Pappone ablate vagal efferent Marine, Prog Card Disease 2005

Pulmonary Vein Isolation

Alternative approach

Success rates for ablation outside the PV “success rates 2-3 times that of antiarrhythmic medications” Verma Circ 2005

Complication in Modern Series JACC 2009;53: K procedures, 32.5 K patients, 162 centers -Between 1995 and in 1000 mortality

Cost in Medicare Dollars -50% unsuccessful

Theory: Prevention Paroxysmal AF Persistent AF years Hypertension Sleep apnea RAAS activation Fibrosis Diastolic Dysfunction Altered substrate Altered electrophysiology Permanent AF

Non-Antiarrhythmic Agents for Afib prevention

Summary Highly prevalent condition with significant associated morbidity and mortality –Driven mostly by thromboembolic events Decision to pursue rhythm control based on patient symptoms Rhythm control –Anti-arrhythmics still 1 st line –Ablative or surgical therapy- case by case